complaint·March 19, 2025

resident’s authorized representative would have to be called multiple times to assist with R1’s behavior. It is alleged that facility neglected to identify the resident’s change of condition. Interview with 2 of 2 staff revealed that they observed R1 to have a change in behavior in November of 2023. Staff stated that they did not observe resident to have any other change of condition. Staff indicated that they did not observe a change in R1’s physical appearance to be able to identify a change of condition. Staff gave R1 a shower on a daily basis that included a visual body check, and no changes were noted as well. It is alleged that resident sustained a stage 4 pressure injury. Interview with 2 of 2 staff revealed that there was no skin tear or wound on R1. R1 was on a daily shower schedule where body checks were conducted by staff and no skin tear, no wound, no redness, or mal odor was observed. Records from Senior Care indicate that the physician’s assistant on February 6, 2024, first learned that R1 had a stage 4 ulcer. However, records indicate that a visit was done on January 4, 2024, and January 5, 2024, with no mention of an ulcer. R1 was moved out of the facility on December 31, 2023. Interview with Senior Care physician’s assistant revealed that R1 had been under their care since prior to December 31, 2023. A visit was done with R1 on March 4, 2024, in which it was observed R1’s health was declining and that was the first time it was learned that R1 had an ulcer. Physician’s assistant had two prior visits before February 6, 2024, and was not aware or informed of an ulcer. Interview with private caregiver revealed that they had cleaned R1 in their bed and changed their diaper the day R1 was removed from the facility and did not observe any redness or a wound and no odor. Based on the information gathered by the department during the investigation, there was not enough evidence to corroborate the following allegations: facility did not seek medical attention in a timely manner, facility did not inform the resident’s representative of the change of conditions, facility neglected to identify the resident’s change of condition and resident sustained a stage 4 pressure injury. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.